90703 (tetanus) and 97542

90703 (tetanus) and 97542

Ok, I am billing for a PCP and have had some problems with the above CPT's. First, I thought I was reimbursed in the past by Medicare for a tetanus injection on an open wound. I know they don't pay for the booster. Am I incorrect?? Will they pay for a tetanus injection??

Also, my physician did a "wheelchair training/assessment" on a patient. I had never coded for one before. I used 97542 x 2 units (1 unit is 15 min) Medicare denied as "proc code inconsistent with the modifier used, or a required modifier is missing". I did not use any modifier, nor can I find one that seems appropriate.

The 97542 code is a PT code so they are looking for the GP modifier SERVICES DELIVERED UNDER AN OUTPATIENT PHYSICAL THERAPY PLAN OF CARE.

I'm not sure about the code you used for the tetanus injection. Wouldn't you use the administration code and the J code J1670? Not sure if the drug itself is covered but the administration should be covered. I would think medical necessity would apply here but not my area of expertise.

Medicare does pay for Tetanus with open wound codes only. If you don't use one of those open wound codes, then it is non-covered and you will need an ABN in place to bill the patient. I use 90714 for billing Td (dx for immunization is V06.5), but if it's for injury, then use the open wound codes. Also, payment may be dependent on your Part B carrier. Check with your carrier as well.

I have also had great difficulty getting Medicare to pay for a Tetanus Injection with an open wound. I have billed the injection code and the J3490 (tetanus toxiod) and also used the 'AT' modifier acute injury. Medicare continue to deny the J3490 stating lacks info. Should I be using the 90703 instead of the J3490??

http://www.wpsmedicare.com/part_b/policy/active/local/l30147_inj012.shtmle. Tetanus serum (J1670) is indicated for transient protection against tetanus post-exposure to tetanus (V03.7). Documentation in the progress notes must identify the following: - The wound is other than a clean minor wound, and the date of the injury; - The active immunization with tetanus toxoid is unknown or uncertain; or - The patient has received either less than 2 prior doses of tetanus toxoid; or two prior doses of tetanus toxoid, but there has been a delay of 24 hours or more between the time of injury and the initiation of tetanus prophylaxis.

My doctor saw a Medicare patient who had cut herself while working in her garden. He cleaned and then sutured the laceration and gave her an injection of Tetanus/Diphtheria (T/D) vaccine before she left the office. Medicare denied the T/D vaccine saying it was not medically necessary. How do we get paid for a tetanus shot for a Medicare patient?

A:

Medicare does not currently pay for the T/D vaccine – they consider it preventive and it doesn’t happen to be one of the preventive services they cover. However, the program does cover CPT 90703 (0.5 ML Tetanus Toxoid), but only in the event of an injury. You need to make sure you bill a diagnosis with the vaccine that supports an injury – i.e., ICD-9 code 883.0 (open wound finger).

If the patient wants one of the T/D vaccines (CPT 90714 or CPT 90718), you can administer it and give the patient an advance beneficiary notice (ABN) and receive payment from the patient. If you do this, make sure you attach modifier GA to the vaccine code, which indicates the patient signed an ABN, and you can then collect directly from the patient.